Although the emergency department (ED) has been heralded as a crucial setting for suicide risk detection and prevention efforts, accurately detecting and effectively managing suicide risk during routine clinical care has been under-developed and under-studied. The Emergency Department Safety Assessment and Follow-up Evaluation - 2 (ED-SAFE-2) represents an unparalleled opportunity to study both the sustainability of successfully implemented universal suicide risk screening and implementation of a brief suicide intervention, the Safety Planning Intervention, into routine care in eight EDs across the country. Investigators: The Project Team has extensive expertise in ED-based suicide screening, assessment, and management (Boudreaux, Camargo, Miller, Manton); safety planning (Stanley, Brown); industrial engineering and healthcare quality improvement (QI) (Johnson, Pelletier, Dickson); qualitative research (Mattocks); effectiveness trial design and analysis (Barton); and multi-center suicide research project management (Arias). Combined, the team has over 100 publications related to suicide prevention and constituent domains. Innovation: In addition to pioneering both the implementation and long-term sustainability of suicide risk screening and safety planning in the ED, the ED-SAFE-2 will be one of the first to study the prominent QI strategy called Lean using a systematic, rigorous approach. In addition, it will innovate healthcare services research methods by applying novel statistical strategies to analyze data from a stepped wedge design. Approach: This effectiveness trial will use a stepped wedge design with the eight original ED-SAFE sites. Quantitative and qualitative data will be collected across three phases: Baseline, Implementation, and Maintenance. Aim 1 will measure the long-term sustainability of universal suicide risk screening (intervention target) and screening's impact on risk detection (patient outcome). Aim 2 will measure the effective implementation of clinician-administered safety planning (intervention target) and safety planning's impact on suicide and suicide-related acute healthcare (suicide composite outcome). Aim 3 will measure and model long- term sustainability of safety planning. In addition, for each Aim, Lean's mechanisms of action will be modeled, including changes in organizational characteristics and enabling infrastructure. Environment: With the success of the original ED-SAFE and other relevant projects, UMass and the partnering institutions have clearly established their capability of successfully carrying out this study. Impact: The innovative approach to be employed in this study position it for a significant impact on the fields of suicide prevention, emergency medicine, QI, and effectiveness trial design and analysis. No other study can answer all of the important research questions posed in this application in one study. Because similar challenges face the study of suicide risk screening and management in other settings, including inpatient, primary care, and specialty care, the deliverables will have broad significance beyond the ED setting.